First-trimester sonographic diagnosis of massive subchorionic

Cumhuriyet Tıp Dergisi
Cumhuriyet Medical Journal
Cumhuriyet Tıp Derg 2009; 31: 71-74
Cumhuriyet Med J 2009; 31: 71-74
First-trimester sonographic diagnosis of massive
subchorionic hemorrhage: a case report
Büyük subkoryonik hemorajinin ilk trimester sonografik tanısı: olgu sunumu
Çağlar Yıldız, Ali Çetin, Hatice Özer, Ayşe Gonca İmir Yenicesu, Gönül Saray
Departments of Obstetrics and Gynecology (Prof. A Çetin, MD, Assist. Prof. A. G. İ. Yenicesu,
MD; Ç. Yıldız, MD), and Pathology (Assist. Prof. H. Özer, MD; G. Saray, MD) Cumhuriyet
University School of Medicine, TR-58140 Sivas
Abstract
We present a 23-year-old woman was admitted due to vaginal bleeding at 14 weeks of gestation to
our outpatient clinic. At 16th week of gestation, ultrasound examination showed a massive
subchorionic hemorrhage at the anterior wall of the uterus with a size of 10 cm in length, 8 cm in
width, and 2.2 cm in depth and extending to the posterior wall of the uterus through the cervix. At
the 32 weeks of gestation the subchorionic hematoma disappeared. At the 38th week of the
gestation successful vaginal delivery was performed without any complication. A good perinatal
outcome was obtained with careful surveillance of maternal and fetal condition.
Keywords: Subchorionic hemorrhage, first trimester, pregnancy.
Özet
Polikliniğimize 14. gebelik haftasında vajinal kanama şikayeti ile başvuran 23 yaşındaki bir bayan
hastayı sunuyoruz. Gebeliğin 16. haftasında yapılan ultrasonografi boyutları 10 cm uzunluğunda, 8
cm genişliğinde ve 2.2 cm derinliğinde olan, uterus ön duvardan başlayarak serviksi katedip uterus
arka duvara uzanan büyük bir subkoryonik hemorajiyi göstermiştir. Gebeliğin 32. haftasında
subkoryonik hematom kaybolmuştur. Gebeliğin 38. haftasında komplikasyonsuz olarak başarılı bir
vajinal doğum gerçekleştirilmiştir. Maternal ve fetal durumun dikkatli takibi ile iyi bir perinatal
sonuç elde edilmiştir.
Anahtar sözcükler: Subkoryonik hemoraji, ilk trimester, gebelik.
Geliş tarihi/Received: March 12, 2009; Kabul tarihi/Accepted: April 18, 2009
Corresponding author:
Dr. Çağlar Yıldız, Kadın Hastalıkları ve Doğum Anabilim Dalı, Cunhuriyet Üniversitesi Tıp
Fakültesi, TR-58140 Sivas, Email: [email protected]
Introduction
Vaginal bleeding is a common problem in the first trimester, occurring in 20 to 40 percent
of pregnant women [1, 2]. Vaginal bleeding in the presence of a closed cervix and
ultrasonographic visualization of an intrauterine pregnancy with positive fetal cardiac
activity is diagnostic of threatened miscarriage. In patients with threatened miscarriage,
vaginal bleeding does not always result in pregnancy loss, even after repeated episodes or
large amounts of bleeding in the first trimester. The bleeding may be a result of disrupted
decidual vessels due to a separation at the subchorionic area.
Transvaginal or transabdominal ultrasonography is the cornerstone of the evaluation of
bleeding in early pregnancy. Intrauterine hematomas are commonly observed features on
ultrasound examinations, especially among patients with clinically evident bleeding in
72
early pregnancy [3]. If a small amount of bleeding is present, it cannot be visualized with
ultrasonographic examination, but when it is large enough, it can appear as a hematoma.
It may found in the subchorionic, retroplacental, and preplacental area.
We report a case of massive subchorionic hemorrhage diagnosed in the first trimester and
showed successful recovery with a good perinatal outcome.
Case report
A 23-year-old woman, gravida 2, para 1, at 14th week of gestation first admitted to our
clinic with the complaint of brown staining vaginal bleeding with no relation to
intercourse and without cramping. She had no significant past medical history and had a
unremarkable previous pregnancy, in addition, there was no history of trauma. The
vaginal examination revealed no abnormality related to vagina, cervix, or uterus.
Transabdominal ultrasound showed a single fetus with a normal heart rate. The placenta
was located on the posterior wall of the uterus and no evidence of subchorionic
hemorrhage at the ultrasonographic evaluation. The bleeding resolved but she was
readmitted at 16th weeks of gestation with recurrent vaginal bleeding. Ultrasound
examination showed a subchorionic hemorrhage at the anterior wall of the uterus with a
size of 10 cm in length, 8 cm in width, and 2.2 cm in depth and extending to the posterior
wall of the uterus through the cervix (Figure 1).
Figure 1. Representative ultrasound image of subchorionic hematoma (SH: subchorionic
hematoma, P: placenta).
There was no intra-amniotic small floating debris. Vital signs were normal and complete
blood count showed that the hemoglobin level was 13 g/dL. Second trimester screening
with triple test (MS-AFP, uE3, hCG) showed a low risk for trisomy 21. She was treated
with oral hydration, oral magnesium citrate 300 mg daily and bed rest. After five days of
hospitalization, the patient discharged with no vaginal bleeding. Screening ultrasound at
the 20th week of gestation showed no fetal anomaly. The patient managed on an
outpatient basis until 38th gestational week and there was no intrauterine growth
restriction and the amniotic fluid index was within reference range. During this period the
patient did not have any obstetrical problem, ultrasound examination revealed that there
was a gradual decrease in the size of subchorionic hematoma and at the 32th week of
gestation, the subchorionic hematoma disappeared. At the 38th week of the gestation,
spontaneous uterine contractions began and successful vaginal delivery was performed
without any complication. A male infant weighing 2900 g was delivered with Apgar
scores of nine and ten at one and five minutes, respectively. During macroscopic
Cumhuriyet Tıp Dergisi
Cumhuriyet Medical Journal
Cumhuriyet Tıp Derg 2009; 31: 71-74
Cumhuriyet Med J 2009; 31: 71-74
73
examination of the placenta and membranes, there was an area of subchorionic hematoma
5x5 cm in size. On microscopic examination, there was areas of focal infarction,
intervillous hemorrhage, and fibrotic mature villi (Figure 2, 3).
Figure 2. Representative microscopic picture of placental infarct (x4).
Figure 3. Representative microscopic picture of subchorionic hematoma (x4).
Discussion
Although hematomas vary significantly in shape and size, most follow the arch of the
uterus and form a crescent-shaped fluid collection or a heterogeneous-appearing space in
a retroplacental or subchorionic area between the chorion and the myometrium [3, 4]. The
incidence of subchorionic hemorrhage is thought to be about 3% to 48% in the general
population during the first trimester [5, 6]. The largest series describing subchorionic
hematomas involving the examination of 19,000 placentas concluded that the incidence
of massive subchorionic hematomas was 1 in 2,000 pregnancies [7]. Numerous studies
have examined the effect of the presence of a subchorionic hemorrhage on perinatal
outcome.
Cumhuriyet Tıp Dergisi
Cumhuriyet Medical Journal
Cumhuriyet Tıp Derg 2009; 31: 71-74
Cumhuriyet Med J 2009; 31: 71-74
74
The presence of a subchorionic hematoma in the first and early second trimester increase
the risk of abnormal perinatal outcome including miscarriage, stillbirth, abruptio placenta,
and preterm labor; however, the size of the hematoma does not seem to be significant [3].
Second trimester bleeding is under-recognized and is worthy of a more lengthy evaluation
owing to a higher rate of fetal loss and maternal morbidity than earlier presentations of
vaginal bleeding [8].
The clinical picture resulting from the placental hematomas is extremely variable, with
several factors probably coming into play including the site and size of hematoma,
gestational age, chronicity of bleeding and underlying disease process [9]. Although there
is no agreement in the clinical management of such patients, careful surveillance of
pregnancy is needed. In our case, a good perinatal outcome was obtained with careful
surveillance of maternal and fetal condition.
References
1.
Ananth C, Savitz D. Vaginal bleeding and adverse reproductive outcomes: a metaanalysis. Paediatr Perinat Epidemiol 1994; 8: 62–78.
2.
Axelsen SM, Henriksen TB, Hedegaard M, et al. Characteristics of vaginal bleeding
during pregnancy. Eur J Obstet Gynecol Reprod Biol 1995; 63: 131–4.
3.
Nagy S, Bush M, Stone J, Lapinski RH, Gardó S. Clinical significance of subchorionic
and retroplacental hematomas detected in the first trimester of pregnancy. Obstet Gynecol
2003; 102: 94-100.
4.
Ozcan T, Pressman EK. Imaging of the Placenta. Ultrasound Clin 2008; 3: 13-22.
5.
Pearlstone M, Baxi L. Subchorionic hematoma: a review. Obstet Gynecol Surv 1993; 48:
65-68.
6.
Nagy S, Bush M, Stone J, Lapinski RH, Gardó S. Clinical significance of subchorionic
and retroplacental hematomas detected in the first trimester of pregnancy. Obstet Gynecol
2003; 102: 94-100.
7.
Shanklin DR, Scott JS. Massive subchorial thrombohaematoma (Breus’ mole). Br J
Obstet Gynaecol 1975; 82: 476-487.
8.
Hodgson DT, Lotfipour S, Fox JC. Vaginal bleeding before 20 weeks gestation due to
placental abruption leading to disseminated intravascular coagulation and fetal loss after
appearing to satisfy criteria for routine threatened abortion: a case report and brief review
of the literature. J Emerg Med 2007; 32: 387-392.
9.
Loi K, Tan KT. Massive pre-placental and subchorionic haematoma. Singapore Med J
2006; 47: 1084-1086.
Cumhuriyet Tıp Dergisi
Cumhuriyet Medical Journal
Cumhuriyet Tıp Derg 2009; 31: 71-74
Cumhuriyet Med J 2009; 31: 71-74